What is the management for a patient with ST-Elevation Myocardial Infarction (STEMI) in a male medicine ward?

Management of STEMI in a Male Medicine Ward

All STEMI patients must undergo immediate reperfusion therapy, with primary PCI performed within 90-120 minutes of first medical contact as the definitive strategy, or fibrinolytic therapy initiated within 30 minutes if PCI cannot be achieved within this timeframe. 1

Immediate Assessment and Triage

Upon recognition of STEMI in the medicine ward:

• Transfer the patient immediately to a PCI-capable center - do not delay for additional testing or stabilization unless the patient is in cardiogenic shock requiring hemodynamic support 1
• Obtain 12-lead ECG within 10 minutes if not already done to confirm persistent ST-elevation 1
• Place on continuous cardiac monitoring for arrhythmia detection 1
• Assess for contraindications to reperfusion therapy, particularly prior stroke/TIA (absolute contraindication to fibrinolytics) and active bleeding 2, 3

Reperfusion Strategy Decision

The critical decision point is whether primary PCI can be performed within 120 minutes of STEMI diagnosis:

If Primary PCI Available Within 120 Minutes:

• Transfer directly to catheterization laboratory, bypassing further ward care 1, 4
• For patients <75 years with large anterior infarction presenting within 2 hours of symptom onset, this window narrows to 90 minutes 1, 4
• Primary PCI is the preferred strategy with superior outcomes compared to fibrinolysis 3, 5

If Primary PCI Cannot Be Achieved Within 120 Minutes:

• Initiate fibrinolytic therapy immediately within 30 minutes using a fibrin-specific agent 3, 1
• Tenecteplase is preferred as a single weight-adjusted IV bolus: 30 mg (<60 kg), 35 mg (60-69 kg), 40 mg (70-79 kg), 45 mg (80-89 kg), 50 mg (≥90 kg) 3
• Reduce tenecteplase dose by 50% if patient ≥75 years old to reduce stroke risk 3
• All patients receiving fibrinolysis must be transferred to a PCI-capable center immediately after administration for angiography between 2-24 hours post-fibrinolysis 3, 1

Immediate Medical Therapy (Initiate in Ward Before Transfer)

Antiplatelet Therapy:

• Aspirin 162-325 mg chewed immediately (non-enteric coated for faster absorption) 2, 1
• Add prasugrel 60 mg loading dose if primary PCI is planned and patient has no history of stroke/TIA 1, 6, 4
• Use clopidogrel 600 mg loading dose if fibrinolysis planned or if prasugrel contraindicated 3, 4

Anticoagulation:

• Unfractionated heparin as weight-adjusted IV bolus followed by infusion for primary PCI 1
• Enoxaparin IV followed by subcutaneous if fibrinolytic therapy administered 3

Symptom Management:

• Morphine sulfate 2-4 mg IV with increments of 2-8 mg at 5-15 minute intervals for pain control and anxiety reduction 2, 1
• Avoid routine oxygen unless SaO2 <90% 1
• Avoid nitrates if systolic BP <100 mmHg or patient recently used phosphodiesterase-5 inhibitors (contraindicated for 48 hours after tadalafil) 2, 7

Beta-Blockers:

• Oral beta-blocker should be administered promptly unless contraindications exist (frank heart failure, hypotension, bradycardia) 2
• Avoid beta-blockers acutely in patients with pulmonary congestion or signs of low-output state 2

Critical Pitfalls to Avoid

Do not keep the patient in the medicine ward for "stabilization" - every minute of delay increases myocardial necrosis and mortality 7, 5. The medicine ward is not an appropriate location for ongoing STEMI management beyond initial triage and medication administration 2.

Do not administer nitrates if:

• Systolic BP <100 mmHg or >30 mmHg below baseline 2
• Patient used phosphodiesterase-5 inhibitors within 48 hours (can cause fatal hypotension) 7
• Right ventricular infarction suspected 2

Do not use streptokinase for fibrinolysis - fibrin-specific agents (tenecteplase, alteplase) are superior 3

Do not delay reperfusion for laboratory results - the diagnosis is clinical and electrocardiographic 4

Post-Fibrinolysis Management (If Applicable)

• Assess for successful reperfusion at 60-90 minutes by evaluating ST-segment resolution (>50% resolution indicates success) 3
• Perform rescue PCI immediately if fibrinolysis fails (<50% ST-segment resolution) or if hemodynamic/electrical instability develops 3, 1
• Transfer to PCI-capable center for angiography between 2-24 hours after successful fibrinolysis 3, 1

Special Considerations for Complications

If Cardiogenic Shock Present:

• Primary PCI remains preferred over fibrinolytic therapy 3
• Intra-aortic balloon pump (IABP) recommended for shock not quickly reversed with pharmacological therapy 2
• Early revascularization (PCI or CABG) recommended for patients <75 years who develop shock within 36 hours of MI 2

If Pulmonary Congestion/Heart Failure Present:

• Oxygen supplementation to maintain SaO2 >90% 2
• Morphine sulfate for pulmonary congestion 2
• ACE inhibitors starting with low-dose captopril (1-6.25 mg) unless systolic BP <100 mmHg 2
• Nitrates unless systolic BP <100 mmHg 2
• Diuretics (furosemide, torsemide, or bumetanide) if volume overload present 2
• Avoid beta-blockers and calcium channel blockers acutely 2

The fundamental principle is that the medicine ward serves only as a brief triage point - definitive STEMI management requires immediate transfer to interventional cardiology facilities 2, 1.